(In this article, the authors present a case followed by a discussion of strategies to address this patient’s needs. Though similar in style to a clinical case conference, our discussion centers on the psychosocial, rather than medical, aspects of care that profoundly impact our patients’ lives.)
Case Presentation
Next in clinic, you have a 53-year-old man with non-obstructive CAD, hyperlipidemia, and gout. Upon chart review, you notice he has been in the emergency department 16 times in 12 months for various pain concerns. He has had 3 different primary care providers over the past 2 years; you find that his last PCP discharged him for “behavior concerns.” He saw a psychiatrist once in the past year who diagnosed him with severe generalized anxiety disorder and possible obsessive-compulsive disorder. He has a low IQ of 79.
You enter the room with trepidation and find a pleasant, anxious man. He feels “rather well” today and just wants to establish care, so you proceed to better understand why he has such a troubling history. He lives with his brother, whom he describes as “mean.” He was very close to his father who, unfortunately, passed away 3 years ago and his life has “been bad” since this time. He completed high school and some technical school. Although he is currently unemployed and relies upon SSI benefits, he has had jobs in the past and enjoyed them. You discuss his frequent ED visits and he expresses a desire to change and reduce them. You mutually agree to a goal for him to apply for a job by your next visit in 2 weeks and for him to call you instead of going to the ED. You leave the visit feeling surprised at your success.
After a promising first visit, problems arise. He calls the clinic up to 30 times per day. Your nurse and social worker note that he often hangs up mid conversation or acts in a bizarre fashion on the phone, including mimicking staff or staying silent for long periods of time. He misses multiple visits and will often schedule, cancel, and re-request to schedule the same visit. His behaviors appear focused on getting attention. When he comes in, he has not made any progress toward completing the goals. After 4 months, you note he has had 33 ED visits. You and your staff are stressed and on edge. There have been requests to discharge him from the clinic, but you feel that isn’t right.
Case Discussion
Although this patient’s specific issues are unique, it is likely that many internists have worked with patients with some similar behavior patterns. These behaviors present challenges to a traditional healthcare system in terms of resource utilization, staff time and energy, and disruption to the care of other patients. In this discussion, the following seven clinicians who specialize in coordinating care for complex patients offer their perspectives:
Dr. Hilgeman and Angela Becker, APSW: What approaches might you employ to help address this patient’s behavior?
One tool that is often underemployed in primary care is a Memorandum of Understanding (MOU). This document can help care teams and patients develop a mutual understanding on how to best interact with the clinic. Overall, this document should be written in positive terms, incorporate the patient’s input, reflect his/her background, and focus on the desired behaviors.
There are 4 key elements that should be included in this document: 1) rationale for the document; 2) key parties included in the MOU; 3) expectations of both the patient as well as the clinic or provider; and 4) consequences for not following the agreed-upon expectations (if appropriate) and specific time frame.
It is important that this document is shared with all care providers involved with the patient so it is consistently enforced. For a patient like ours, when limits are set in one department but not another, the behaviors can often escalate.
Dr. Henschen: How would you address these behaviors when he shows up in the Emergency Department?
Establishing consistent boundaries, both over time and across settings, may address his behaviors and preserve staff wellness. Our team of physicians and social workers creates stand-alone behavioral plans that delineate these boundaries to clinicians. We partnered with our IT department to create notifications alerting us when our patients are in the ED, alerting ED staff toward the behavior plan, and recommending they contact us directly during business hours. We also can be a sounding board, so their frustrations can be directed toward us rather than toward the patient. In that way, our team aims to be a source of support to the staff of our hospital system.
Even if your system does not have the capability to implement automated alerts, proactively reaching out to ED teams with recommendations a few times will help establish a pattern. Your recommendations may become ‘chart lore’ and can be carried forward without the need to reach out indefinitely. Although every patient presents unique challenges, promoting consistency, clear boundaries, and open communication between the clinic and the ED are important first steps.
Drs. Bryk and Leon-Jhong: How might clinicians uncover the underlying causes of challenging patient behavior?
Seeking further understanding behind a “challenging” patient’s behaviors is important not only to provide effective care, but also to avoid physician burn-out. Patients who are recognized as acting outside of social norms, either overly aggressive or overly submissive, should be screened for trauma.1 Patients who have experienced trauma are more likely to have physical and mental health conditions and more likely to overutilize health care. We generally ask, “Is there anything I need to know to help me take better care of you?”
Once a clinician is aware of past trauma, it can inform the way that they care for the patient. In this case, we may find that the death of the patient’s father left him abandoned, seeking out attention in any form. Our goal in this case would be to establish the clinic and doctor-patient relationship as a stable, safe, supportive force, but establish clear expectations and boundaries.2 For example, we may arrange for the doctor to call the patient at a certain time each week or that we will return calls within 24 hours. This can help the patient to not feel abandoned as they work to build positive coping skills.
Dr. Tang and Nicole Gier: How would you maintain personal wellness while caring for a patient like this?
Before entering a conversation or visit with a patient who triggers distress, consider taking a “mindful moment.” This moment could involve taking a deep breath and allowing whatever thoughts and feelings that show up to be present without judgement. Acknowledge that this is a difficult situation and validate to yourself that your emotional response is normal and human. Consider asking yourself: “What do I need to do or hear right now?” An encouraging word or a gesture such as holding your own hand can be a kind response to pain.
Your values can also be a guide in tough moments. Consider writing down and carrying with you a written reminder of why you engage in this challenging work. One of the authors carries in her wallet a note that reads, “while this moment may be difficult to bear, I am here to be of service and be helpful where I can.”
Finally, consider engaging your colleagues, nurses, social workers, trainees, and other team members in processing and validating the experience of caring for patients whose behaviors impact us. Sharing the experience of our own distress can make us feel less alone and remind us of how much we have in common with one another.
Conclusions
Although there isn’t a single solution that can meet the needs of every patient with challenging behaviors, a set of common strategies may provide a way forward. Memorandums of understanding can help to set expectations and promote positive behaviors. Clear communication strategies with acute care providers can make life easier for everyone. Determining whether underlying trauma plays a role can help the patient as well as the care team. Lastly, maintaining wellness by acknowledging that you are entering a difficult situation, tapping into your values, and engaging support from colleagues can give you the strength to persist and thrive in this work. Using these approaches to address patients with complex needs may improve care while supporting the clinicians in their vital work.